APPLICATION
First Name
Last Name
Email
Phone
Birthday
Time of Birth (Please provide if you'd like me to pull your astrological birth chart.)
Birth city (Please provide if you'd like me to pull your astrological birth chart.)
Where are you located?
How did you hear about us? (Google, Instagram, Referral?)
Where in your life do you feel the most misaligned?
What are the top 3 nagging loops or thought patterns that keep showing up that hijack you from being in the pleasure of the present moment (aka worrying about what has happened, anxious about what might happen next)?
Describe your relationship to your body:
Describe your relationship to money:
What is the big dream that turns you on and freaks you out?
Have you been hospitalized or professionally treated for any medical or psychological condition in the past 5 years?
Select
Select
Yes
No
Are you on ANY prescription medications? If so, what are they, quantity taken, how many times a day, and for how long have you been taking them? If not, just put NO in the box below.
I, the signee of this application, NOW take 100% responsibility for my physical, mental, emotional, spiritual, financial, sexual, and ALL ENERGY and transactions in the relationship between myself and Kimberly Dam.
100 percent!
No
Please type I AM followed by YOUR NAME
Today's Date
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